Sixty-four percent of people in the Adult Dental Health Survey for the United Kingdom (Kelly et al 2000) stated that they were frightened by some forms of dental treatment. Furthermore the Survey (Kelly et al 2000) showed convincingly that fears concerning dental treatment were not related to dental attendance pattern. Over forty percent of adults irrespective of their dental attendance pattern were fearful of some aspects of treatment. For adults who are dentally anxious (Moore et al 200, Kleinknecht et al 1973) it is the pain associated with the local anaesthetic injection and the drill which is the most feared aspect of dental treatment.

Similar patterns of dental fear are found in children (Carson and Freeman 2000). Children who have and have not regular patterns of dental attendance admit to being fearful of some forms of dental treatment. In general these fears are in relation to the drill and injection. Interestingly the least feared item for all children was the polishing cup used in prophylaxis.

Dentists must be in the position to provide objective and empathetic care for all patients in their care. For the most part patients will accept the treatment that is being provided. However a problem arises when patients are too fearful, or if their fears are fixed upon the local anaesthetic injection and/or the drill and/or if they present in pain. In such situations the dentist must be able to provide care quickly and in a manner that will not unduly distress the patient. Hence there is a need for the dentist to be able readily to identify dentally anxious patients who may be amenable to dental treatment in the practice setting. Furthermore the need to have a non-invasive treatment modality that needs little time and abnegates the need for the injection or the drill would assist in the clinical management of the dentally anxious patient or those who present in pain.

The aim of this chapter is to provide the dentist with a schema with regard to the identification of the dentally anxious patient. The schema is based upon detailed history taking and the use of dental anxiety questionnaires to assess anxiety status. In addition the chapter aims to demonstrate the usefulness of Ozone as a new treatment modality in the care of the dentally anxious patient.

In descriptive terms dental anxiety describes the fearful patient who attends for treatment. The anxious patient is usually, pale, quiet or withdrawn and unable to maintain eye contact. In explanatory terms all energies are taken up with the feared situation the patient is unable to connect, speak or form any type of interaction with the dentist – his energies are elsewhere - as Florence Nightingale stated:

‘Remember [the patient] is face to face with his enemy all the time,internally wrestling with him, having long imaginary conversations with him’.

Entering the dental surgery, seeing the dental chair and instruments revives the occasion that initially gave rise to the anxiety. This present day experience diverts the patient’s energies and forms a nexus of fear from which the patient is unable to flee. Hence Coriat’s (1946) view that the patient experiences an ‘anticipatory anxiety’ and a ‘fear of the unknown’ provides an explanation as to why the anxious patient fears dental treatment in the ‘here and now’. It is as if the past has caught up with the present and the patient fears experiencing the original terrifying dental treatment all over again. This is what the patient internally and eternally wrestles with and about which (s)he has the long imaginary conversations. The amount of anxiety experienced in quantitative terms will affect the ability of the patient to form a treatment alliance and accept the treatment the dentist is offering and providing.

Dental anxiety in Coriat’s (1946) explanatory framework is associated with the past and is the relived in the ‘here and now’ of dentistry which results in the anticipatory anxiety and the fear of the unknown. For many patients with dental anxiety identifying the anxiety-provoking experience and ventilating fears, worries and concerns will allow the formation of the treatment alliance and accept the care the dentist is offering and providing.

If the construct of dental anxiety is to be fully understood it is necessary to revisit the notion that it is the amount of anxiety experienced in a quantitative sense which holds the key. Working with some patients who refuse to accept dental treatment suggests that the intensity of anxiety experienced is so great it results in avoidance of dental treatment – descriptively they are ‘phobic’ of dental treatment. It seems that in terms of the quantity of dental anxiety there must be an additional, cumulative factor which provides the increased intensity of anxiety which results in the avoidance of treatment. It has been suggested that such patients have made a ‘false connection’ between traumatic experiences that have occurred outside the dental surgery with a frightening dental event that has occurred inside. In order for a false connection to occur the two situations must have some element(s) in common and two psychological processes must be operative. The first process is the displacement and substitution of anxiety from one situation (outside the dental surgery) to another (inside the dental surgery) and the second, the concentration of anxiety onto dental treatment. The anxieties from experiences outside the dental surgery are transferred onto dental treatment. The intensity of the accumulated anxiety becomes so great that it is both psychologically and physiologically unbearable for the patient. The result is the avoidance of dental care. For the purposes of this chapter the meaning of false connections and displacement (Freeman 1998) are given as:

false connections, are misunderstandings. They happen in childhood as a result of confusion of what has been seen, heard or experienced in one situation with what has seen, heard or experienced in another. The misunderstanding or confusion arises because the two situations have one or more elements in common.

displacement describes the transfer or shift of emphasis from one situation, person or idea to another. With the transfer or shift in emphasis there is the formation of substitutes for the situation, person or idea.

The DAS was developed by Corah (1969) to assess adult dental anxiety. It is a four item inventory. The questions ask about the intensity of dental anxiety when waiting for, first the day of the appointment, secondly in the waiting room, thirdly for drilling and finally for scaling. Examples of questions to assess anxiety when visiting the dentist to-morrow and waiting in the waiting room for treatment are:

[1] If you had to go to the dentist to-morrow, how would you feel ?

1

Would look forward to it as a reasonably enjoyable experience

Y/N

2

Wouldn’t care on way or the other

Y/N

3

Would be uneasy about it

Y/N

4

Would be afraid

Y/N

5

Would be very frightened

Y/N

[2] While you are waiting in the waiting room for your turn in the dentist’s chair, how do you feel?

1

Relaxed

Y/N

2

Uneasy

Y/N

3

Tense

Y/N

4

Anxious

Y/N

5

So anxious, I feel sick and break out in a sweat

Y/N

Each question has 5 possible responses from feeling relaxed (scoring 1) to feeling anxious (scoring 5). This gives a possible range of scores from 4 to 20 with the score of 8.89 representing the population average score. Scores between 17 and 20 correspond to dental phobia.

The MDAS was developed in 1995 by Humphris et al(Humphris et al, 1995. This is a modification of Corah’s scale and includes a question about local anaesthesia. The questions assess the intensity of dental anxiety when waiting for, first the day of the appointment, secondly in the waiting room, thirdly for drilling and for scaling and finally for local anaesthesia. Examples of questions to assess dental anxiety when waiting for a dental appointment and treatment are:

[1] If you went to your dentist for TREATMENT TOMORROW, how would you feel ?

1

Not anxious/b>

Y/N

2

Slightly anxious

Y/N

3

Fairly anxious

Y/N

4

Very anxious

Y/N

5

Extremely anxious

Y/N

[2] If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel?

1

Not anxious

Y/N

2

Slightly anxious

Y/N

3

Fairly anxious

Y/N

4

Very anxious

Y/N

5

Extremely anxious

Y/N

The scoring system is the same as for the DAS with total scores ranging from 5 to 25. Scores above 19 indicate dental phobia with 10.97 being the population average, for people attending general dental practitioners.

The MCDAS was developed by Wong et al in 1998 to assess children’s dental anxiety when having dental general anaesthesia (DGA) or relative analgesia (RA). The questionnaire consisted of 8 items. A score of 1 relaxed/not worried to 5 very worried. It has been modified to include faces (Figure 1). The scores range from 8 to 40.

Figure 1: The Modified Child Dental Anxiety Scale

1

going to the dentist

1

2

3

4

5

2

having your teeth looked at

1

2

3

4

5

3

having your teeth scraped & polished

1

2

3

4

5

4

having an injection in the gum

1

2

3

4

5

5

having a filling

1

2

3

4

5

6

having a tooth out

1

2

3

4

5

7

being put to sleep for treatment

1

2

3

4

5

8

having a mixture of gas and air tomake you feel comfortable but not asleep

Combining the patient’s history and scores from the psychological questionnaires to assess dental anxiety the dentist is now in a position to identify the patient with dental anxiety, phobic reactions and for whom their dental phobia is merely a symptom of a greater psychological disturbance. Working in this way the dentist is forging the treatment alliance in preparation for the next stage of care that is negotiating the treatment plan.

Examining the links between reported fears and dental anxiety status Freeman (1991) suggested that memory acted to distort the original frightening dental treatment experience. The difficulty with the distortion was that the dentally anxious patient would perceive each new dental treatment experience as potentially harmful. In this heightened state of anxiety patients would be more likely to recall, re-experience and learn more about events which corresponded to their mood. Essentially a vicious circle of anxiety would be developed and with it the incubation and maintenance of the patient’s dental anxiety.

This work suggested that if patients were given a ‘corrective dental experience’ within a framework of behavioral management it would be possible to cut the vicious circle of dental fear and assist patients to contain their dental fears and accept treatment. However the need to use alternative treatment modalities that abnegated the need for the injection or the drill and would allow the patient to accept the treatment offered and provided by the dentist remained until recently an unresolved problem.

With the advent of Ozone as an alternative to conventional restorative techniques, such as local anaesthesia, drilling and filling, it seemed that Ozone would be a useful treatment modality for the management of dental anxious patients requiring conservative treatment. Ozone is currently being used in a variety of clinical settings. Ozone treatment for dental decay has been shown to reverse carious process in just a single application. Dental ozone devices deliver ozone for 30 - 60 seconds via a delivery tip onto the tooth area requiring treatment. In terms of its non-invasive mode of application and the short treatment time, it seems ideal in terms of a treatment modality for the dentally anxious patient.

Recent research on 377 patients (Domingo et al 2002) who required conservative treatment for two carious lesions assessed patients’ attitudes, satisfaction and dental anxiety status with regard to conventional conservative treatment and treatment with Ozone. The patients were asked to complete a questionnaire prior to and after treatment with Ozone and conventional restorative treatment for their carious lesions respectively. The questionnaire assessed their satisfaction with treatment, their dental anxiety before and after treatment and contrasted dental anxiety status with regard to conventional dental treatment and Ozone. The Modified Dental Anxiety Scale (Humphris et al 1995) was used to assess dental anxiety.

The findings from this preliminary work are positive and encouraging. Nearly all of the patients stated that they were happy and satisfied with the Ozone treatment. The reduced time in the dental chair was perceived as a highly desirable characteristic of the new treatment. All of the patients stated that Ozone was their preferred treatment option - irrespective of the financial costs. In terms of their dental anxiety status patients were less anxious before and after Ozone treatment compared with conventional treatments for their carious lesions.

It is known that large proportions of patients (Kelly et al 2000) attending for dental treatment show varying degrees of apprehension, worries and anxieties that may result in avoidance of dental treatment. As the majority of people perceive the injection and the drill to be the most fearful aspects of dental treatment it would seem that non-invasive methods of treating the carious lesion must have a role to play in the clinical management of the dentally anxious patient. Ozone treatment, which requires no local anaesthesia, drilling or filling and is completed from 10 seconds, is an ideal solution for those patients who are dentally anxious. The reduction of dental fear experienced by those receiving Ozone compared with conventional methods of caries management suggested that Ozone provided a new treatment modality for dental anxiety management.